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FOR OFFIC~ USE O<.NLYI <br />Received By:/.2,~, ,q ~ <br />l To.i.g Validation:ff e ~_ [ <br /> <br /> BUILDING PERMIT APPLI~oubiT¥ <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 ~[II[DI~O INSp£~TiON <br />1. Job Description <br /> <br /> RESII)ENTIA L - ~OM. MERCIAL ( )New ....... U~e of Structure: ~ <br /> ( )Addition ( )Relocation ( )Addition ( )Sign C~./~9 ~ <br /> ( ) ~erafion ( )Demo~fim ( )Almmfion ( )DemoHfim ~B <br /> (~cces5o~ ( )~er ( ) Change of Occupancy ( )Othur <br />..... /o -- <br />.. / O~cupant Lind or Number of Employees <br />'~< > o~ ,~,r~ ~ ~o- ~o~ [ ....... No, ~m~: ...... <br /> <br />2. Location of Installation <br /> <br /> ~m~a,//~ ~¢ q7%~"' s~s;~"' <br /> 8ubdivi~im ~t l~l(~k <br />~o~ ~o~, .~ ....... ~e. ~ cee..~ ~r, ~ ..... '""' , ~,~.. ~6 ....... ' .... <br /> Semion ~.~ Townshlp ~X Range &O~ Z., ~ M,p WaterSupplV": <br /> <br />................. Communi2}'Well ( ) City (~' <br /> <br />3. Contractor Information <br />l'vokx~rty Owner,~m W_,, ,~' ~'b0 g.O [ MaiHng Add.ss '~' Phone <br />( ) I own, mslde in. or will mslde in the completed simware. <br /> <br /> ( ) [ unders[a~ld thai I must resistor a~ a ¢OnSlmcfion contractor if tho sm*crum is ~old or offered ~br sale before or u~m c(~llplcl~. <br /> (~1~ will be rny own g~eral contractor <br /> <br /> ) r am a registered builder OR the authoriT, ed representative of a regis~red builder. <br /> <br />Architect,~ame: I Mail_inS Address: I Pr°ne; I <br /> Fee Schedule <br /> <br />A, VALUATION (See "Valuation Schedule" <br /> <br /> to determjn0 valoarion based on <br /> <br /> (1) Permk Fee <br /> <br /> (2) 5% State Surcharge (.05 x Al) <br /> <br /> (3) Stnlcmral Plan Review (.65% x Al) <br /> <br /> (4) Fm~ & Life Safety Plan Review (.40% <br /> <br />(1) Driveway w/curb ('~ $7.50 <br />(2) Driveway w/o curb Q/$1'lJ×) = __ .... <br />(3) Sim Plan Review (commercial only) @ $79.(Xl = . ....... <br />(4) Additional Plan Reviews or Addendmns <br />(5) Investigation Fee = <br />(6) Reinspeetion Fee (0 $25.00 <br /> <br /> (5) 7x n ! Surcharge. if applicable (.05% x A i) ~ ~' ~'~'~ (7) Other <br /> Inspection q <br /> li¥cd <br /> <br />m~cr~e fide of ~is form. <br /> <br />MC 15-73 Rev. 11/91 <br /> <br /> <br />